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    Wasisno FR Mandibula, Cor

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    Mrprads5
    1) A 52-year-old male patient presented with head and jaw pain after falling and hitting his chin on a rock while farming. 2) On examination, he had a laceration on his chin that was sutured, facial swelling, limited jaw opening, and a broken tooth. 3) CT scan showed commotio cerebri and fractures of the parasymphysis and condyle of the mandible.

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    Wasisno FR Mandibula, Cor

    Uploaded by

    Mrprads5
    20 views12 pages
    1) A 52-year-old male patient presented with head and jaw pain after falling and hitting his chin on a rock while farming. 2) On examination, he had a laceration on his chin that was sutured, facial swelling, limited jaw opening, and a broken tooth. 3) CT scan showed commotio cerebri and fractures of the parasymphysis and condyle of the mandible.

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    Wasisno Fr Mandibula, Cor

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    1) A 52-year-old male patient presented with head and jaw pain after falling and hitting his chin on a rock while farming. 2) On examination, he had a laceration on his chin that was sutured, facial swelling, limited jaw opening, and a broken tooth. 3) CT scan showed commotio cerebri and fractures of the parasymphysis and condyle of the mandible.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    Download as pptx, pdf, or txt
    20 views12 pages

    Wasisno FR Mandibula, Cor

    Uploaded by

    Mrprads5
    1) A 52-year-old male patient presented with head and jaw pain after falling and hitting his chin on a rock while farming. 2) On examination, he had a laceration on his chin that was sutured, facial swelling, limited jaw opening, and a broken tooth. 3) CT scan showed commotio cerebri and fractures of the parasymphysis and condyle of the mandible.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 12

    NAMA : Tn.

    W
    UMUR : 52 thn
    CM : 01456880
    STATUS : BPJS
    Keluhan Utama :
    Nyeri dan luka pada kepala dan rahang setelah KLL
    RPS :
    Enam jam SMRS saat pasien sedang bercocok tanam
    disawah, tiba-tiba pasien terpeleset dengat dagu membentur
    batu. Pingsan (+), muntah (-), kejang (-). Setelah kejadian
    pasien mengeluh nyeri kepala dan rahang bawah. Oleh
    penolong pasien dibawa ke puskesmas, dijahit luka. Karena
    dirasakan nyeri memberat, pasien dibawa ke RSDM
    Primary Survey

    A : Clear
    B : I : Pengembangan dada kanan = kiri, RR: 20 x/mnt
    P : krepitasi (-/-)
    P : Sonor/sonor
    A : SDV (+/+), ST (-/-)
    C :N: 83 x/mnt, TD : 109/81mmHg
    D :GCS E4V5M6 pupil (3mm/3mm) isokor , RC (+/+)
    E : S: 36,8 0C, Jejas (+) lihat status lokalis
    Secondary Survey

    • Kepala : t.a.k
    • Mata : Visus >2/60 / > 2/60, gerak bola mata dbn,
    hematom periorbita(-/-)
    • Hidung : darah kering (-/-)
    • Telinga : tragus pain (+/+)
    • wajah : lilhat status lokalis
    • Leher : t. a. k
    • Thorax : t. a. k
    • Abdomen : t. a. k
    • Genitalia : t. a. k
    • Extremitas : t. a. k
    Status Lokalis
    R. Midfacial :
    I : oedema (-/-), pendataran malar iminens (-/-),
    telecantus (-) jarak intercantal 3,5 cm, floating
    maksila (-)
    P : hipoestesia n.infraorbita (-/-)

    R. Intraoral :
    I : maloklusi (+) open bite, trismus (+) 1 cm, gigi patah
    (-), lacerasi mucogingiva (-)
    P: step off (+), gigi goyang (+) incicivus 1 kiri atas

    R. MandibulaI :
    I : asimetris (-), vulnus terjahit r mentale 4 simpul
    dengan silk 2.0
    P : hipoestesi n. Mentale (-/-)
    ASSESMENT I :
    COR GCS E4V5M6 (S06.1)
    Comotio Cerebri (S06.0)
    Susp. Fr Parasymphisis Mandibula (S02.6)
    Susp Fr Condyle (D) mandibula (S02.61)

    PLAN I :
    Head Up 30 °
    Oksigen 3 lpm
    Infus NaCL 0.9% 1500 cc/24 jam
    Inj Metamizole 1 gr/8 jam
    Cek Laboratorium darah
    Ro Orthopantomogram
    Kepala AP, waters
    CT Scan Kepala
    CT Scan
    ASSESMENT II :
    COR GCS E4V5M6 (S06.1)
    Commotio Cerebri (S06.0)
    Fr Paraymphisis Mandibula (S02.60) AO 91.S
    Fr Condyle (S) mandibula AO (S02.61) AO 91.P.m

    PLAN II :
    Bedah Saraf:
    Konservatif
    Awasi KU/VS/GCS/Tanda lateralisasi

    Bedah Plastik:
    Oral Hygiene
    Diet Cair
    ORIF elektif (mandibular plate + MMF)
    Jam Datang 01.25
    Jam Triage 01.30
    Jam Bedah 01.40
    Jam Laboratorium 01.50– 02.30
    Jam Radiologi 02.00 – 02.45
    Jam Diagnosa 02.50
    Jam MRS 03.10

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